What is the AC Joint in the shoulder?
The top of the shoulder blade or scapula is the acromion. The joint formed where the acromion connects to the collarbone or clavicle is the AC joint. Usually there is a protuberance or bump in this area, which can be quite large in some people normally. This joint, like most joints in the body, has a cartilage disk or meniscus inside and the ends of the bones are covered with cartilage. The joint is held together by a capsule, and the clavicle is held in the proper position by two heavy ligaments called coracoclavicular ligaments.

How is the AC Joint usually injured?
The AC joint is injured most often when one falls directly onto the shoulder. The trauma will separate the acromion away from the clavicle, causing a sprain or a true AC joint dislocation. In a mild injury, the ligaments which support the AC joint are simply stretched (Grade I), but with more severe injury, the ligaments can partially tear (Grade II) or completely tear (Grade III). In the most severe injury, the end of the clavicle protrudes beneath the skin and is visible as a prominent bump

How is an AC Joint separation diagnosed?
Most often the clinical exam will demonstrate tenderness or bruising around the top of the shoulder near the AC joint. The suspected diagnosis can be confirmed using an x-ray, which compares the injured side with the patient's normal.

What is the proper treatment for a sprained AC Joint?
When a joint is first sprained, conservative treatment is certainly the best. Applying ice directly to the point of the shoulder is helpful to inhibit swelling and relieve pain. The arm can be supported with a sling, which also relieves some of the weight from the shoulder. Gentle motion of the arm can be allowed to prevent stiffness. Exercise of the elbow, wrist, and hand are very helpful. Any attempts at vigorous shoulder mobilization early on will probably lead to more swelling and pain

How long does it take for a shoulder separation to heal?
It may take weeks to months to heal depending on the severity of injury. In severe cases, the shoulder may not heal without surgery

When and why is surgery necessary for AC Joint separations?
Usually surgery is reserved for those cases where there is residual pain or unacceptable deformity in the joint after several months of conservative treatment. The pain can occur with direct pressure on the joint, such as with straps from underwear or work clothing. Sometimes there will be catching, clicking, or pain with overhead activities, such as lifting, throwing, or reaching. Finally, in some people with very thin skin and very little muscular and soft tissue padding above their shoulders, the prominent clavicle after the separation may be considered unattractive.

Are there other causes of AC Joint pain and disability?
Arthritis can occur as an isolated event in the AC joint, causing stiffness, aching, and sometimes swelling. Another condition called DCO, or distal clavicle osteolysis, gives a similar picture, usually in young people who lift heavy weights. This is called "Weightlifter's Shoulder."

What type of surgery can repair AC Joint problems?
The simplest type of surgery for AC joint injury involves resection or removal of the end of the clavicle using arthroscopic or mintoper techniques. If the joint becomes painful because of DCO (weightlifter's shoulder) or arthritis, or the separation is only minor, this technique can be very satisfactory. When the joint is severely displaced, then a more complex ligament reconstruction procedure is needed to restore the position of the clavicle.

What is the postoperative treatment and rehabilitation?
Postoperatively, treatment depends on the type of surgery performed. Usually, when the Mumford procedure is performed the arm can be treated with a sling. Bathing is allowed in three days' time, and elbow, wrist, and hand exercises are begun immediately. Lifting is limited for three weeks, but following that, progressive exercise and motion activities proceed as the symptoms allow.

When a ligament reconstruction procedure (rebuilding of the torn ligaments) is needed, approximately two or three weeks is added to the immobilization time before motion exercises are begun. This time allows the ligament to heal. Otherwise, the exercise program is the same as that for the Mumford procedure above.

How can I get more information about AC Joint injuries?
Please feel free to call Western Orthopaedics, PC at Local:303-321-1333 or toll free at 1-888-900-1333 and ask for a referral to a shoulder specialist. One of the physicians will be happy to answer your questions and evaluate your shoulder in the clinic.

Adhesive Capsulitis/Frozen Shoulder
What is adhesive capsulitis?
Adhesive capsulitis is the technical term for “Frozen Shoulder”. The shoulder joint is supported by ligaments which connect the shoulder bones together and keep them properly aligned when in motion. Normally, the ligaments are flexible enough to permit full movement of the shoulder. When adhesive capsulitis occurs, the ligaments develop an inflammatory process, causing them to be infiltrated with scar tissue and form very restricting adhesions. This “freezing” of the joint severely decreases the shoulder’s normal range of motion and can cause a considerable amount of pain when motion is attempted.

Who is most at risk?
Women 40 years of age and older are most likely to develop frozen shoulder. Some medical conditions, such as diabetes, thyroid disease, or prion trauma, can be associated with frozen shoulder, but the conditions can and often does occur in any normal individual, male or female, without any predisposing medical condition or trauma.

How do the symptoms develop?
Adhesive capsulitis progresses through three general phases. The symptoms of the first phase, or “freezing phase”, is the insidious onset of generalized pain about the shoulder which is increased with movement, and results in loss of motion. It is felt that, because of the pain resulting from the inflammation, the patient elects to protect the shoulder by no moving it, thereby setting the stage for the scar tissue that binds the shoulder even tighter. The second phase, or “frozen phase”, is distinguished by localized pain and tenderness and discomfort that seems to worsen at night and often interferes with sleep. During this phase, the inflammation is slowly subsiding and the scar tissue is maturing. The final phase, or “thawing phase”, embodies a less painful shoulder but with significantly decreased range of motion. During this phase, the scar tissue may begin loosening up and shoulder motion can slowly return.

How is a diagnosis of adhesive capsulitis made?
The diagnosis of frozen shoulder is usually made by an orthopedic surgeon. The symptoms of shoulder pain are often confused with such things as calcific bursitis, rotator cuff tears, arthritis, or tendinitis. Although these more serious conditions are thought to sometimes precede adhesive capsulitis, in most cases, that is not necessarily true, and the condition is an isolated event. When the surgeon notices a decrease in shoulder motion the diagnosis is suspect. When x-rays, MRI, and physical exam rule out other causes of pain, then the diagnosis is confirmed.

How is adhesive capsulitis treated?
The treatment of adhesive capsulitis depends on the stage and severity of the condition. Often, in the early stages, oral anti-inflammatory medications are helpful to decrease the joint inflammatory reaction, hopefully thereby decreasing the scar tissue formation by allowing more pain-free range of motion. In addition, physical therapy modalities, including phonophoresis (sometimes with cortico-steroids), ultrasound, and hot and cold treatments can be helpful. A physical therapist who is familiar with this condition is also very helpful in performing active-assisted and passive gentle manipulative range of motion activities. Frequently this is best done in a warm therapy swimming pool situation. A home exercise program, using overhead pulley and stretching activities with a cane or wand, must be included in the therapy program.

Pain or analgesic medicines are often necessary to help with the discomfort, particularly during the “frozen phase”.

Surgery is rarely needed for adhesive capsulitis. Surgery begins with manipulation under anesthesia. In our practice, this is usually performed in the outpatient department. With the patient asleep, the physician attempts to manipulate the shoulder through a full range of motion to stretch the tight scar tissue surrounding the joint. In more serious cases, it is sometimes necessary to perform an arthroscopic surgery and release additional adhesions. Following manipulation, the patient must continue physical therapy and home exercises. On occasion, two or sometimes three manipulations are needed since the adhesions may reform if the inflammatory process remains active.

What is the long-term outlook for frozen shoulder?
Most cases of frozen shoulder eventually resolve, either spontaneously, or following physical therapy and sometimes manipulation. This condition does not lead to arthritis or rotator cuff tendon damage. Despite the fact that the shoulder is considerable disabled for a prolonged period of time, within two years most cases of adhesive capsulitis have resolved. This is the most important thing for a patient to realize, and also, that the condition seldom returns to a joint once it has resolved.

If I have any further questions, who can I call?
Please feel free to call Western Orthopaedics at (303) 321-1333 and ask for a referral to a shoulder specialist. One of the physicians will be happy to answer your questions and evaluate your shoulder in the clinic.

What is the labrum?
The labrum is a ring of cartilage material located around the shoulder socket (glenoid). The labrum helps contribute to the stability of the shoulder by deepening the socket, and helps to cushion the compression across the socket. The biceps tendon attaches to the labrum at the top of the socket. The ligaments that hold the shoulder in the joint attach in the front and back of the labrum.

Who gets labral tears?
Anyone can get a labral tear. Injury can occur due to repetitive use, and may be more likely to occur in individuals who have instability or looseness of the shoulder joint. A special type of labral tear is called a “SLAP lesion”. This is a tear of the top part of the labrum extending from in front to behind the biceps tendon (SLAP – Superior Labrum from Anterior to Posterior). The most common causes of this type of labral tear are traction (as in the jolt one may experience when water-skiing or when trying to reach up and grab an object overhead when trying to save oneself from falling) or compression (as in falling onto an outstretched arm). Often, patients may get either labral tears or SLAP lesions just from repetitive use and without any specific traumatic incident.

What happens when the labrum is torn?
When the labrum is torn, a flap of labrum can move in and out of the joint, causing shoulder pain, locking, catching, snapping, or grinding. This may be related to certain positions of the arm. If the labral tear makes the attachment of the biceps tendon loose, the shoulder joint may become unstable.

How are labral tears treated?
Initially, rest, ice, and gentle anti-inflammatory medicines are used. However, with repetitive use of the arm, it may be very difficult for a labral tear to heal. In this instance, surgery may be indicated.

What does surgery involve?
This depends on the extent and location of the labral tear. Many labral tears can be treated with a simple arthroscopic shaving (debridement) of the torn flap of cartilage. If the tear extends to the biceps tendon (SLAP lesion), reattachment of the labrum and biceps tendon back to the socket (glenoid) may be required. This is done arthroscopically using miniature screws and sutures. If possible, the labrum may be arthroscopically repaired with suture alone. If there is extensive tearing of the biceps tendon in association with the labrum tear, the biceps tendon may need to be reattached to the bone in the upper arm (biceps tenodesis).

What is the usual course after surgery?
Again, this depends on the extent of the labral tearing and the surgery that was performed. If the labrum only needs to be shaved, then a quick return (within one to three weeks) to almost all activities may be possible. However, if the labral tear of SLAP lesion needs to be repaired, then a more gradual return is necessary. A sling is utilized in the first few weeks after surgery, and immediate use of the hand and elbow is encouraged.

Desk work and light duty can usually be resumed within the first week or two; return to heavy labor usually takes two to four months.

How can I get more information about labral tears or SLAP lesions and treatment?
Please feel free to call Western Orthopaedics, PC at Local:303-321-1333 or toll free at 1-888-900-1333 and ask for a referral to one of the shoulder specialist. One of the physicians will be happy to answer your questions and evaluate your shoulder in the clinic